SURRENDER OF A CHARITABLE COLLECTION LICENCE BY LICENSEE
Charitable Collections Act 2003
Charitable Collections Regulation 2003
		
PURPOSE 

This form is to be used when surrendering a licence under Section 29 of the Charitable Collections Act 2003 (the Act).  You can access the legislation at www.legislation.act.gov.au.  You may also obtain further information and forms at www.ors.act.gov.au.
	
PRIVACY

The Act authorises the Director-General to collect the personal information required by this form for the purposes of issuing a licence under Division 4.1 of the Act.  Pursuant to Section 41 of the Act, the Director-General must keep a Register of Licenses that is available for inspection by the public. The Director-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (C’wlth).  The Director-General may provide additional information to law enforcement agencies and authorised organisations that have legal authority to request information under prescribed circumstances.
	
CONTACT
	
Office of Regulatory Services Shopfront
255 Canberra Avenue, Fyshwick ACT 2609	Office of Regulatory Services Postal Address
GPO Box 158, Canberra ACT 2601	
Opening Hours 9:00am to 4:30pm Monday to Friday	Website www.ors.act.gov.au      Email ors.bil@act.gov.au 	
General Enquiries (02) 6207 0562
	Fax Number (02) 6207 0424
	
INSTRUCTIONS FOR COMPLETION 
•	Complete this form using blue or black pen only.
•	Please print; ensuring writing is clear and legible. 
•	This office will not accept lodgement of this form if it is not completed in full.	
IMPORTANT INFORMATION
•	Licensees should be aware of their responsibilities under the Charitable Collections Act 2003. 
•	Licensees surrendering a Charitable Collection Licence are required to provide finalized accounts within 120 days after the surrender date by completing the Financial Reports to the Director-General for a Charitable Collection form.
•	Where the amount of the collection from ACT residents is less than $50,000 please complete the form, including the collection details.
•	Where the amount of the collection from ACT residents is $50,000 or more please complete this form and attach audited statements of the collection.
•	If the collection includes monies collected from other Australian States and Territories it is permissible to report on the whole collection if you are unable to distinguish between that collected from the ACT and that collected elsewhere.
•	The Licensee must return the original licence to the Director-General.
	
TRANSLATING AND INTERPRETING SERVICE
If you require further information or require advice, a language assistance service is available by phoning the Translating and Interpreting Service (TIS) on 13 14 50.	

                  

SURRENDER OF A CHARITABLE COLLECTION LICENCE 
BY LICENSEE
Charitable Collections Act 2003
Charitable Collections Regulation 2003	

NAME OF LICENSEE	LICENCE NUMBER	DATE SURRENDERED	LICENCE ATTACHED	
			 Yes	 No	

DETAILS OF NOMINATED OFFICER OR CONTACT PERSON	

TITLE (e.g. Ms, Mr, Dr)	FULL NAME 	POSITION HELD WITHIN ORGANISATION (E.g. Exec Officer)	
			
ADDRESS (Property name, unit, flat, room no, street number, street name, city/suburb/town, postcode)	

SIGNATURE NOMINATED PERSON OR CONTACT OFFICER	

Applicant’s Name in Full

Applicant Signature                                      Date       /      /       	Signed in my presence

Witness’s Name in Full

Witness Signature                                  Date     /      /       

STATUTORY DECLARATION BY LICENSEE IF THE LICENCE IS NOT ATTACHED TO THE APPLICATION	

I …………………………………………………………………………….of……………………………………………………………………….
(Name)                                                                                         (Address)
………………………………………………………………………………………………………………………..
(Occupation)

hereby declare that the Charitable Collection Licence No                                  issued to ……………………………………………………has been lost, mislaid or destroyed.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statement in this declaration is true in every particular.

Declared at ………………………………………………on the ……………………day of ……………………………………….20

Signature of person making the declaration ………………………………………………………………………………………….

Signature of person before whom the declaration is made  ……………………………………………………………………….

Address of person before whom the declaration is made …………………………………………………………………………Qualification* ………………………………………….

Full name, qualification* and address of person before whom the declaration is made (in printed letters) (* Must be authorised under Statutory Declarations Act 1959)